Anaphylaxis
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ANAPHYLAXIS. ANAPHYLAXIS . The first documented case of anaphylaxis was in 2641 B . C . , when Pharaoh Menes of Egypt died from a Wasp sting.  While the first fatal reaction to peanuts was described by a Canadian researcher Dr Evans in 1988 .

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Anaphylaxis

ANAPHYLAXIS


Anaphylaxis1

ANAPHYLAXIS

  • The first documented case of anaphylaxis was in 2641 B.C., when Pharaoh Menes of Egypt died from a Wasp sting.  While the first fatal reaction to peanuts was described by a Canadian researcher Dr Evans in 1988.

  • Allergy to venom from wasp stings can cause anaphylaxis as can allergy to latex and drugs such as penicillin and aspirin. Bee sting allergy is less common in the UK.


Anaphylaxis2

ANAPHYLAXIS

  • The most common cause of anaphylaxis in the community is from eating a food to which you are allergic such as nuts, peanuts, eggs, mammalian milk, soya, wheat, fish and shellfish.  These 8 foods account for 90% of cases of food induced anaphylaxis.  Peanuts and tree nuts (such as Brazil nuts, Hazelnuts, Almonds and Walnuts) are the foods most likely to provoke a reaction.


Anaphylaxis3

ANAPHYLAXIS

  • Some people may develop anaphylaxis after eating certain foods such as celery, shrimps, wheat, apple, hazelnut, squid and chicken and then exercising shortly after ingesting the food – triggering Exercise Induced Anaphylaxis.


Systemic anaphylaxis

SYSTEMIC ANAPHYLAXIS

  • Most extreme over-reaction of immune system

  • Caused by allergens which reach bloodstream

    • Venomous insect stings

    • IV and IM drugs

    • PO drugs (rapid absorption and high bioavailability)


Anaphylaxis ige mediated

Anaphylaxis- IgE-mediated

  • Antibiotics and other medications

    Penicillins, β-lactams, tetracyclines, sulfas, vaccines, immunotherapy

  • Foreign proteins

    Latex, hymenopteravenoms, heterologous sera,

    protamine,

  • Foods

    Shellfish, peanuts, and tree nuts

  • Exerciseinduced


Systemic anaphylaxis1

SYSTEMIC ANAPHYLAXIS

  • Mechanism is widespread activation of mast cells throughout body resulting in

    • Vascular permeability (circulatory collapse / anaphylactic shock)

    • Constriction of smooth muscles

  • Death by constriction of airways and swelling of epiglottis


Anaphylaxis4

ANAPHYLAXIS

  • Signs within 5 to 30 min (very rarely hours)

  • Recurrent (biphasic) anaphylaxis – occurs 8-10haftertheinitialattack

  • Persistent anaphylaxis – can last for up to 32h


Signs and symptoms of systemic anaphylaxis

SIGNS AND SYMPTOMS OF SYSTEMIC ANAPHYLAXIS

Signs/Symptoms :

  • Skin and soft tissue

    • Flushing, pruritis, urticaria and angioedema

  • Cardiovascular:

    • Syncope, tachycardia or no pulse,hypotension, cardiacarrhythmias

  • Nervous

    • Apprehension, convulsions, headache, unconsciousness

  • Gastrointestinal

    • Vomiting, diarrhea, abdominal cramps,nausea,

  • Respiratory

    • Wheezing, dyspnoe,bronchospasm


Anaphylaxis5

Anaphylaxis

  • Skin signs:

  • - erythema, urticaria, pruritis,


Anaphylaxis

  • Anaphylaxis

  • Skin signs:

  • - pruritis, angioedema


Anaphylaxis6

ANAPHYLAXIS

  • The most common symptoms were urticaria and angioedema, occurring in 88% of patients. The next most common manifestations were respiratory symptoms, such as upper airway edema, dyspnoe and wheezing. Cardiovascular symptoms of dizziness, syncope, and hypotension, were less common, but it is important to remember that cardiovascular collapse may occur abruptly, without the prior development of skin or respiratory manifestations.

  • Other symptoms of rhinitis, headache, substernal pain, and pruritus without rash were less commonly observed.


Most common clinical manifestations of anaphylaxis

Most Common Clinical Manifestations ofAnaphylaxis

Symptom… Howoften?

  • Urticaria /Angioedema 88%

  • Upper airwayoedema56%

  • Dyspnoe/ bronchospasm 50%

  • Flushing 51%

  • Cardiovascularcollapse “Anaphylacticshock” 30%

  • GI 30%


Anaphylaxis treatment

ANAPHYLAXIS TREATMENT

  • Prevention- avoidtheallergen

  • People with asthma and/or allergy have the risk of anaphylaxis, especially those with un-controlled asthma and/or severe allergy risk. These people should consult to an allergy specialist. When the anaphylaxis trigger has been identified by allergy testing, you must avoid the allergen very carefully.


Treatment of systemic anaphylaxis

TREATMENT OF SYSTEMIC ANAPHYLAXIS

  • Epinephrine is drug of choice

  • Sympathicomimetic drug acting on

    • Alpha receptors of vascular endothelium

    • Beta receptors of bronchial smooth muscles

  • Administered by I.M. injection into antero- lateral thigh

    • Do not inject into buttock

    • Do not inject I.V.

      • Cerebral hemorrhage

  • Epinephrine Auto-Injector (EpiPen)

    • Adult (0.3 mg) and pediatric (0.15)


How to give epinephrine

How to GiveEpinephrine?


How to give epinephrine1

Howto GiveEpinephrine?

In themuscle….

WhichMuscle?

Lateral

Thigh


How to give epinephrine2

How to GiveEpinephrine?


Epipen epipen jr directions for use

EpiPen/EpiPenJr: Directions for Use


Anaphylaxis

EpiPen/EpiPenJr:

Directions for Use


Anaphylaxis

EpiPen/EpiPenJr:

Directions for Use


Use of epi pen

Use of EpiPen….

  • No contraindications in anaphylaxis !!!

  • Failure or delay associated with fatalities

  • I. M. may produce more rapid, higher peak levels vsS. C.

  • Must be available at all times


Anaphylaxis

ADMINISTRATION OFintramuscular ADRENALINEIntramuscular injection of epinephrine intothe tigh – more effective than injection intothe arm or subcutaneous administration


When to repeat epinephrine

When to RepeatEpinephrine?

• PracticeParameterUpdate - US

  • – Repeat every 5 minutes as needed to control symptoms andbloodpressure

  • – Some guidelines suggest liberalizing the frequency if deemednecessary – no absolute contraindication for epinephrine

    • UK Consensus Panel on emergency Guidelines and

    International consensus guidelines for emergency

    cardiovascularcare

  • – May judiciously be repeated as often as every 5 minutes


Who should get epinephrine

WhoShould Get Epinephrine?

Everyone with rapid progression of symptoms

  • Laryngealedema

  • Bronchospasm

  • Severe GI symptoms

  • Hypotension

  • Highest fatality rates when epinephrine is delayed

  • Age is not a limiting factor


Anaphylaxis treatment first line

AnaphylaxisTreatment –First Line

ESTABLISH AIRWAY and supplemental O2

• I.V. fluids

• Pulmonarysymptoms: Albuterol by nebulization or MDI

• Deterioration of pulmonarysymptoms : Racemicepinephrine by nebulization; Considerintubationortracheostomy


After the epi second line therapy for everyone

After The Epi –Second Line Therapy ForEveryone

Antihistamines: H1 + H2 blockers

  • Diphenhydramine25-50 mg IV/IM/PO

    1 mg/kg PO/ IM/ IV (kids)

  • Ranitidine•50 mg IV…….. 4 mg/kg PO up to 300 mg

    1.5 mg/kg IM/IV up to 50 mg (kids)


What about non sedating h 1 blockers

What About Non-Sedating H-1 blockers?

  • Cetirazine (Zyrtec) 10 mg po q day

  • Loratidine (Claritin) 10 mg po q day

  • Desloratadine (Clarinex)5 mg po q day

  • Fexofenadine (Allegra)180 mg po qday

  • Only available in oral form, longrecord of efficacy with urticaria


Other second line considerations

OtherSecond Line Considerations

  • Inhaledbeta-agonists - ifwheezing

  • Corticosteroids

    – 1-2 mg/kg prednisone PO

    – 1-2 mg/kg methylpredisolone IV (max 250 mg)

  • Not helpfulacutely

  • ? Preventrecurrentanaphylaxis

  • Glucagon ( ifbeta blocked) 1-5 mg slow IV, 1-5 ug/min


Treatment of anaphylaxis

Treatment of Anaphylaxis…

  • Observe for a minimum 8-12 hours

  • Rebound or persitantsymptoms

    • Repeat epinephrine, repeatantihistamine ± H2 blocker


This is a simple instruction of injecting epipen

This is a simple instruction of injecting EpiPen:

  • Pull the seal cover.

  • Put the black tip on your upper thigh (no need to undress the patient, unless the fabrics is too thick).

  • Strongly press the EpiPen into your thigh until you feel the injection done.

  • Hold the EpiPen for 10 seconds.

  • Release the EpiPen while slowly massage the injected area.

  • Call for medical help/ambulance.

  • If the symptoms have not reduced after 30 minutes while you are waiting for medical help, give the second injection.


Anaphylaxis fatalities

Anaphylaxis Fatalities

  • Estimated 500–1000 deaths annually

  • 1% risk

  • Risk factors:

    • Failure to administer epinephrine immediately

    • Peanut, Soy & tree nut allergy (foods in general)

    • Beta blocker, ACEI therapy

    • Asthma

    • Cardiac disease

    • Rapid IV allergen

    • Atopic dermatitis (eczema)

  • Miller RL. Epidemiology of anaphylaxis. Presented at: Anaphylaxis: Safely Managing Your Patients at Risk for Severe Allergic Reactions. Postgraduate Institute for Medicine; October 8, 1999; Washington, DC.Bocher BS. Anaphylaxis. N Engl J Med 1991:324:1785–1790


Food induced anaphylaxis incidence

Food-induced Anaphylaxis: Incidence

  • 35%–55% of anaphylaxis is caused by food allergy

  • 6%–8% of children have food allergy

  • 1%–2% of adults have food allergy

  • Incidence is increasing

  • Accidental food exposures are common and unpredictable

    Kemp SF, et al. Anaphylaxis. A review of 266 cases. Arch Intern Med 1995; 155:1749–54.

    Pumphrey RSH, et al. The clinical spectrum of anaphylaxis in northwest England. Clin Exp Allergy 1996; 26:1364–1370.

    Bock SA. Prospective appraisal of complaints of adverse reactions to foods in children during the first 3 years of life. Pediatrics 1987;79:683–688.


Food induced anaphylaxis common symptoms

Food-induced Anaphylaxis: Common Symptoms

  • Oropharynx: Oral pruritus, swelling of lips and tongue, throat tightening

  • GI: Crampy abdominal pain, nausea, vomiting, diarrhea

  • Cutaneous: Urticaria, angioedema

  • Respiratory: Shortness of breath, stridor, cough, wheezing


Food induced anaphylaxis fatal reactions

Food-induced Anaphylaxis: Fatal Reactions

  • Fatal reactions are on the rise

    • ~150 deaths per year ( in US )

    • Usually caused by a known allergy

  • Patients at risk:

    • Peanut and tree nut allergy

    • Asthma

    • Prior anaphylaxis

    • Failure to treat promptly epinephrine

  • Many cases exhibit biphasic reaction

    Anaphylaxis Committee, AAAAI. Anaphylaxis. Teaching Slides. 2000.


Venom induced anaphylaxis incidence

Venom-induced Anaphylaxis: Incidence

  • 0.5%–5% (13 million) Americans are

    sensitive to one or more insect venoms

  • Incidence is underestimated

  • Incidence increasing due

  • Incidence rising due to more outdoor activities

  • At least 40–100 deaths per year


Venom induced anaphylaxis common culprits

Venom-induced Anaphylaxis: Common Culprits

  • Hymenoptera

    • Bees

    • Wasps

    • Hornets


Hymenoptera

Hymenoptera


Venom induced reactions common symptoms

Venom-induced Reactions: Common Symptoms

  • Normal:Local pain, erythema, mild swelling

  • Large local: Extended swelling, erythema

  • Anaphylaxis: Usual onset within 15–20 minutes

    • Cutaneous: urticaria, flushing, angioedema

    • Respiratory: dyspnoe, stridor

    • Cardiovascular: hypotension, dizziness, loss of consciousness

  • 30%–60% of patients will experience a systemic reaction with subsequent stings


Venom induced anaphylaxis prevention

Venom-induced Anaphylaxis: Prevention

Risk Management

Keep EpiPen or EpiPen Jr on hand at all times

Educate and train on EpiPen use

Develop emergency action plan

Wear a MedicAlert bracelet

Consult an allergist to determine need for venom immunotherapy


Venom induced anaphylaxis immunotherapy

Venom-induced Anaphylaxis: Immunotherapy

  • Medical criteria

    • Venom immunotherapy is medically indicated in any adult with a history of a systemic reaction to an insect sting, and in children who have had life-threatening sting reactions.

    • Positive venom skin test & sIgE

  • 97% effective

  • Can be discontinued in most after 3–5 years;


Exercise induced anaphylaxis

Exercise-Induced Anaphylaxis

  • First reported in 1979

  • Mechanism of action is unclear

  • Predisposing factors:

    • ASA ,

    • Food, including:shell fish, cheese, dense fruits, snails.

  • Triggered by almost any physical exertion

  • Most common in very athletic children


Exercise induced anaphylaxis1

Exercise-Induced Anaphylaxis

  • Four Phases

    • Prodromal phase is characterized by fatigue, warmth, pruritus, and cutaneouserythema

    • The early phase: urticarial eruption that progresses from giant hives may include angioedema of the face, palms, and soles.

    • Fully established phase: hypotension, syncope, loss of consciousness, choking, stridor, nausea, and vomiting ( 30 minutes to 4 hours.)

    • Late or postexertional phase, Prolonged urticaria and headache persisting for 24-74 hours.


Non ige anaphylaxis

NON-IgE ANAPHYLAXIS

Drugs

  • Opiates

  • NSAIDs

  • ACE inhibitors

    Foods

  • Strawberries

  • Fish e.g. Tuna (Scrombotoxin)


Diagnosing anaphylaxis

Diagnosing Anaphylaxis

  • Based on clinical presentation, exposure

  • Cutaneous, respiratory symptomsmost common

  • Some cases may be difficult to diagnose

    • Vasovagal syncope

    • Systemic mastocytosis


Diagnosing anaphylaxis1

Diagnosing Anaphylaxis

  • Careful history to identify possible causes

  • Can be confirmed by serum tryptase

    • Specific for mast cell degranulation

    • Remains elevated for up to 6-12hours

  • Serum histamine - risesw/in 5 minutes,returnsto baseline after 30-60minutes

  • Other labs to rule out other diagnoses

  • Refer to allergist for specific testing


Diagnosing anaphylaxis2

Diagnosing Anaphylaxis

  • Skin tests/RAST

    • Foods

    • Insect venoms

    • Drugs

  • Challenge tests

    • Foods

    • NSAIDs

    • Exercise

Allergists can identify specific causes by:


Anaphylaxis summary

Anaphylaxissummary…

  • Signs and Symptoms of Anaphylaxis:

    • Urticaria, itching, hives

    • Rash

    • Rhinitis

    • Bronchospasm

    • Laryngeal Edema

    • Syncope

    • Cardiac Arrest

  • Treatment:

    • Basic Life Support:

      • Airway

      • Breathing

      • Circulation

    • Epinephrine  0.3-0.5 ml of 1:1000 IM  Repeat of no response

    • Oxygen

    • Diphenhydramine (antihistamine) 50ml IM

    • Corticosteroids

    • Intubation or cricothyrotomy


Can i predict severe anaphylaxis

Can I Predict Severe Anaphylaxis?

RiskFactors

  • Male

  • Consistentantigenadministration

  • Shorter time elapsed since last reaction < 1 year

  • Asthma


Meet m j

Meet M. J.

  • A 13 y/o girl with a beesting to hand one hour ago

  • Symptoms: swelling, erythemaand pain

  • Treatment and advice?


Treatment and advice

Treatment and Advice

  • Clean area, ice for comfort

  • Removestinger

  • Anti-histamines

  • ? Topicalintermediatepotencycorticosteroidcream (triamciniline 0.1%)

  • ? Systemicsteroids

  • Education/Plan

  • Referral to allergist

  • EpiPen


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